Cyanosis attributable to right to left shunt in the carcinoid syndrome SIR,-Dr G W Stewart and colleagues (1 March, p 589) described an interesting case of pronounced arterial hypoxaemia in a patient with the carcinoid syndrome.In the absence ofpulmonary metastases they attributed the hypoxaemia to intrapulmonary shunting through microscopic arteriovenous fistulas.The data presented, however, do not exclude an alternative explanation-right to left shunting through a patent foramen ovale.Although right to left shunting through the foramen ovale is well recognised in patients with pulmonary hypertension,'"3 it may also occur in the presence of normal pulmonary artery and right heart pressures, apparently as a result of reduced right atrial compliance.4Thus though mean left atrial pressure may exceed mean right atrial pressure, during atrial filling right atrial pressure rises disproportionately, causing phasic shunting across the interatrial septum.Right atrial compliance
The UK Renal Association clinical practice guidelines include clinical performance measures for biochemical variables in dialysis patients. The UK Renal Registry(UKRR) annually audits dialysis centre performance against these measures as part of its role in promoting continuous quality improvement.Cross sectional performance analyses were undertaken to compare dialysis centre achievement of clinical audit measures for prevalent haemodialysis (HD) and peritoneal dialysis (PD) cohorts in 2013. The biochemical variables studied were phosphate, adjusted calcium, parathyroid hormone and bicarbonate.In addition, longitudinal analyses were performed (2002–2013) to show changes in achievement of clinical performance measures over time.Fifty-seven percent of HD and 62% of PD patients achieved a phosphate within the range recommended by the RA clinical practice guidelines. Seventy-eight percent of HD and of PD patients had adjusted calcium between 2.2–2.5 mmol/L. Fifty-seven percent of HD and 63% of PD patients had parathyroid hormone between 16–72 pmol/L. Fifty-nine percent of HD and 79% of PD patients achieved the audit measure for bicarbonate. There was significant inter-centre variation for all variables studied.The UKRR consistently demonstrates significant inter-centre variation in achievement of biochemical clinical audit measures. Understanding the causes of this variation is an important part of improving the care of dialysis patients in the UK.
Infection remains one of the leading causes of mortality in established renal failure patients receiving renal replacement therapy (RRT). Since 2007, centres providing RRT in England have been asked to provide additional data on patients with methicillin resistant Staphylococcus aureus (MRSA) bacteraemia. Since 2011, the option to provide data on methicillin sensitive Stapylococcus aureus (MSSA) and Escherichia coli bacteraemia, as well as Clostridium difficile infection has also been available.Data were submitted to Public Health England by laboratories via HCAI-DCS including whether the patients were receiving dialysis. Individual renal centres then confirmed the record either directly via the database or after being contacted. Data were collected for the period of the 1st May 2011 to the 30th April 2012.There were 49 episodes of MRSA bacteraemia, an overall rate of 0.22 per 100 dialysis patients per year, representing a further year on year fall in MRSA rate. There were a higher number of MSSA episodes, 322 in total, with an overall rate of 1.15 per 100 dialysis patients per year. The number of episodes and overall rate of E. coli and C. difficile were 284 and 0.92 per 100 prevalent dialysis patients per year and 172 and 0.61 per 100 prevalent dialysis patients per year respectively. In each infection type the presence of a central venous catheter appeared to correlate with an elevated risk.Data are presented from one year of infections reported to PHE. The rate of MRSA bacteraemia episodes in England continues to fall. There was a higher rate of MSSA infections amongst renal dialysis patients. Findings from the first year of E. coli and C. difficile data collection are also reported. Future cycles will give us a further idea of the trend in incidences of these infections.
Introduction: Infection remains one of the leading causes of death in patients with end-stage renal failure (ESRF) receiving dialysis. Since April 2007, all centres providing renal replacement therapy in England have been required to provide additional data on patients with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. From January 2011 this has also been required for patients with Methicillin Sensitive Staphylococcus Aureus (MSSA). MRSA data for 2009–2011 and the first 6 months of MSSA data are reported. Methods: Potential bacteraemia were identified by the Health Protection Agency based on clinical details provided and the clinical setting. The records were 'shared' with the parent renal centre who then complete the additional data on the HCAI-DCS website. Centres were also contacted by phone and email as a further validation step. Results: From April 2009–2010 there were 77 confirmed episodes of MRSA bacteraemia at a median rate of 0.25 per 100 prevalent dialysis patients. This number decreased to 61 episodes between April 2010–2011 at a median rate of 0 per 100 prevalent dialysis patients. Overall there has been an 82% reduction in absolute episodes since the first year of mandatory reporting in 2007. The incidence of bacteraemia in patients with a central venous catheter was approximately six fold higher than in those with an AV fistula. From 1st January to 30th June 2011 there were 160 episodes of MSSA bacteraemia with a rate of 1.06 episodes per 100 dialysis patients, again the risk was six fold higher in patients with a CVC. Conclusions: Overall rates of MRSA bacteraemia in dialysis patients continued to fall although there remained variation between renal centres. Initial data from the early days of MSSA reporting suggested high rates of infection and an even greater variation between renal centres. This requires confirmation from future data collection.
Prevention of menstrual migraine by percutaneous oestradiolRoughly 60% of women with migraine relate the periodicity of their headaches to their menstrual cycles, and about a quarter of these women have their headaches exclusively at the time of menstruation.1 2 The physiological withdrawal of oestrogen during the premenstrual phase of the cycle has been suggested to be the precipitating event leading to these menstrual attacks.3We investigated the effect of treatment with percu- taneous oestradiol on menstrual migraine attacks.
ABSTRACT Background Chronic kidney disease (CKD) is common but heterogenous and is associated with multiple adverse outcomes. The National Unified Renal Translational Research Enterprise (NURTuRE)-CKD cohort was established to investigate risk factors for clinically important outcomes in persons with CKD referred to secondary care. Methods Eligible participants with CKD stages G3–4 or stages G1–2 plus albuminuria >30 mg/mmol were enrolled from 16 nephrology centres in England, Scotland and Wales from 2017 to 2019. Baseline assessment included demographic data, routine laboratory data and research samples. Clinical outcomes are being collected over 15 years by the UK Renal Registry using established data linkage. Baseline data are presented with subgroup analysis by age, sex and estimated glomerular filtration rate (eGFR). Results A total of 2996 participants was enrolled. Median (interquartile range) age was 66 (54–74) years, eGFR 33.8 (24.0–46.6) mL/min/1.73 m2 and urine albumin to creatinine ratio 209 (33–926) mg/g; 58.5% were male. Of these participants, 1883 (69.1%) were in high-risk CKD categories. Primary renal diagnosis was CKD of unknown cause in 32.3%, glomerular disease in 23.4% and diabetic kidney disease in 11.5%. Older participants and those with lower eGFR had higher systolic blood pressure and were less likely to be treated with renin–angiotensin system inhibitors (RASi) but were more likely to receive a statin. Female participants were less likely to receive a RASi or statin. Conclusions NURTuRE-CKD is a prospective cohort of persons who are at relatively high risk of adverse outcomes. Long-term follow-up and a large biorepository create opportunities for research to improve risk prediction and to investigate underlying mechanisms to inform new treatment development.
Routine monitoring of outcomes for patients with acute kidney injury (AKI) is important to drive ongoing quality improvement in patient care. In this study we describe the development of a case mix-adjusted 30-day mortality indicator for patients with post-hospitalization AKI (PH-AKI) across England to facilitate identification of any unwarranted centre variation in outcomes.We utilized a routinely collected national dataset of biochemically detected AKI cases linked with national hospitals administrative and mortality data. A total of 250 504 PH-AKI episodes were studied across 103 National Health Service hospital trusts between January 2017 and December 2018. Standardized mortality ratios (SMRs) were calculated for each trust using logistic regression, adjusting for age, sex, primary diagnosis, comorbidity score, AKI severity, month of AKI and admission method.The mean 30-day mortality rate was high, at 28.6%. SMRs for 23/103 trusts were classed as outliers, 12 above and 11 below the 95% confidence limits. Patients with PH-AKI had mortality rates >5 times higher than the overall hospitalized population in 90/136 diagnosis groups and >10 times higher in 60/136 groups. Presentation at trusts with a co-located specialist nephrology service was associated with a lower mortality risk, as was South Asian or Black ethnicity. Deprivation, however, was associated with higher mortality.This is the largest multicentre analysis of mortality for patients with biochemically ascertained PH-AKI to date, demonstrating once again the considerable risk associated with developing even mild elevations in serum creatinine. Mortality rates varied considerably across centres and those identified as outliers will now need to carefully interrogate local care pathways to understand and address the reasons for this, with national policy required to tackle the identified health disparities.
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